Torticollis and its P.T. Management

As part of a class presentation, we attempted to make this to briefly explain what Torticollis meas, the Types of presentation of Torticollis, and Management strategies for a Physiotherapist for Congenital Torticollis especially.

I hope this helps. :)

The pictures and information had been taken from internet, complied to make a brief presentation for the purpose of class presentation.

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1. Torticollis ( Wry neck) By Fabiha Fatima and Falak.

2. So what is “Torticollis” ? Torticollis , also known as  wry neck , is a dystonic condition defined by an abnormal, asymmetrical head or neck position, which may be due to a variety of causes. The term  torticollis  is derived from the Latin words  tortus  for twisted and  collum  for neck

3. Presentation of Torticollis :- Torticollis is a fixed or dynamic tilt, rotation, with flexion or extension of the head and/or neck. The type of torticollis can be described depending on the positions of the head and neck:- LATEROCOLLIS  : the head is tipped toward the shoulder ROTATIONAL TORTICOLLIS  : the head rotates along the longitudinal axis ANTEROCOLLIS  : forward flexion of the head and neck RETROCOLLIS  : hyperextension of head and neck backward

4. Signs and Symptoms Torticollis can be a disorder in itself as well as a symptom in other conditions. Other symptoms include: Neck pain Occasional formation of a mass Thickened or tight sternocleidomastoid muscle Tenderness on the cervical spine Tremor in head Unequal shoulder heights Decreased neck movement

5. Types of Torticollis :-

6. Congenital muscular torticollis

7. Acquired torticollis

8. Acquired Torticollis: Types

9. Other Types of Torticollis Spasmodic Torticollis Recurrent or transient contraction of the muscles of the neck muscles. SCM is mostly involved Cervical dystonia, idiopathic cervical dystonia, intermittent torticollis" Trochlear torticollis ( Congenital fourth nerve palsy) This is unrelated to the SCM Caused by damage to the Trochlear nerve (CN IV) that supplies the Superior Oblique muscle of the eye .

10. Torticollis may lead to additional problems :- Flattening of the skull (plagiocephaly or brachycephaly) in infants. Movement that favors one side of the body, affecting the arms, trunk, and hips. This can lead to strength imbalances, such as an elevated shoulder and side-bending of the trunk. This movement pattern can lead to delayed gross motor development. Developmental hip dysplasia. Scoliosis. Limited ability to turn the head to see, hear, and interact with surroundings, which can lead to delayed cognitive development. Delayed body awareness or lack of self-awareness and interaction. Difficulty with balance. Asymmetrical vision changes.

11. Additional Problem

12. Diagnosis General History taking Birth History History of Trauma Neurological examination X-ray of cervical spine MRI USG – Muscular tissue, Color Histogram Optometrist evaluation

13. Assessment : Observation of any asymmetries including facial, cranial, neck and positional preference and presence of plagiocephaly. Observation of skin creases. Observation of infant in developmentally appropriate positions to detect asymmetry and screen developmental milestones. Cervical active and passive range of movement testing. Upper and lower limb ROM screen, checking for hip dysplasia, which can be associated with CMT, and spine asymmetry. Pain at rest and during movements. Palpation of sternocleidomastoid for size and elasticity and presence of mass. Screen of visual tracking. Screen muscle tone. Identification of Red flags and appropriate onward referral: poor tracking abnormal muscle tone other features inconsistent with CMT poor progress with treatment

14. Management : Physical Therapy (Goals)

15. Physiotherapy Management Early mild cases Children with a mild degree of deformity reporting early for the treatment can be managed with physiotherapy.  The physiotherapy procedures employed are:         I.  Evaluation : Careful evaluation of ROM and the degree of deformity.       II.  Massage:  Massage can relax the muscle preceding the stretching maneuvers.   III. Thermo Therapy Modality: Carefully administered thermo-therapy modality induces relaxation.   IV.  Passive movements:  The child is placed in supine position with head beyond the edge of the table with the neck in extension by positioning a pillow under the thoracic region; Shoulders are stabilized by an assistant.

16. Physiotherapy Management To attain relaxation , all the movements of the cervical spine are done in a form of slow relaxed passive movements. This should be  followed by sustained passive stretching to the affected sternomastoid.  E.g. when the right sternomastoid is involved the head should be gradually bent inside flexion to the left, held there for a while and then rotated gradually to the right. Try to gain as much overcorrection as possible by applying gradual traction to gain further stretching.

17. Physiotherapy Management Maintenance of Correction:  Once the correction is achieved. It has to be maintained by passively holding or keeping a sandbag. E.g : Kineso taping, Cervical Brace, Cervical collars The  same maneuver can be repeated during the subsequent visits . Active correction:  Active correction is best achieved by assisting the child head to follow an object moved in the proper arc of correction. The bright-colored sound producing object is ideal to attract the child attention. PNF:  patients with neck extension can be used to an advantage with emphasis on stretch and traction.

18. Physiotherapy Management Home treatment programme:  This assumes an important role as these manipulations needs to be repeated. The mother should be trained properly for this. The best method is to put the child in prone and the teach the mother to carefully move the head towards the affected side and the child is encouraged to look back over the right shoulder. Positioning:  Exact positioning of the head during sleep is important. The child should be made to sleep on the opposite side of the lesion and the position of head adjusted by pillow or sandbag in a maximally corrected posture during sleep. This positioning has two advantages:- First, there is natural relaxation of the muscle- Secondly, whatever correction is achieved, it is maintained for a longer period during sleep. However, the mother should intermittently check the correction. Older children and adults:  With advancing age the deformity gets organized and does not get corrected by conservative management.

19. Surgical Management Subcutaneous tenotomy, open tenotomy, bipolar tenotomy, and radical resection of a sternomastoid tumor or the SCM.   The sterna and the clavicular heads of sternomastoid are divided close to the origin along with the release of the tight fascia. The head is then immobilized in a plaster cast in over-corrected position for 2 to 4 weeks. Mobilization is begun as soon as the cast is removed.

20. Post surgical PT management Hot packs for pain relief. Active movements of sternocleidomastoid to prevent post surgery weakness. Free active movements in the direction of correction followed by resistive exercises. Self correction in front of mirror. Specially molded cervical collar and maintenance of correction during sleep.